I read with interest the Yu et al.1 commentary on sharing office visit notes with patients. I often read aloud the last office visit notes to my patient at the time of the follow-up visit. I begin this by saying “this is what I documented when I last saw you. Please correct me if I got anything wrong in your history.” I have found this helpful in 2 ways. One, it helps to refresh the history, assessment, and plan in my own mind; and second, it helps engage the patient and accompanying caregiver in his or her care. My experience with this exercise has been a mixed bag. Some patients compliment me for documenting a comprehensive history, while others berate me for getting their hand dominance wrong, or documenting their alcohol intake or use of illicit drugs. Medicine is a science and you call a spade a spade. Alcoholism is not synonymous with social drinking and I fear that physicians would have to water down their notes just to avoid offending the patient. A physician's office notes should be an accurate, objective, and nonjudgmental documentation of the patient rather than a politically correct one. Finally, a physician should never forget that the office note is a medico-legal document, one that can be produced in court and at times used against him or her.
Disclosures:
N. Sethi serves as Associate Editor of The Eastern Journal of Neurology.
- © 2017 American Academy of Neurology
Authors Respond:
We thank Dr. Sethi for his comments on our article1 and for sharing his personal experience with open notes. We agree with his comments and want to emphasize that we do not advocate for watering down clinical documentation. The integrity of the clinical note for its primary purpose is paramount. In addition, although patients may be upset in the short term, calling a spade a spade when it comes to substance use, and the patient's viewing the documentation in the privacy of his or her own home may allow the patient to eventually overcome denial and take action. If a note is felt to be particularly sensitive, the provider should have the option to refrain from releasing the note to the patient as well.
Disclosures:
M.M. Yu has received funding for travel and/or speaker honoraria from the AAN and is a member of the Epic Neuroscience Steering Board. A.L. Weathers has received funding for travel and/or speaker honoraria from the AAN, North Carolina Neurologic Society, and Los Angeles Neurologic Society; serves on the Editorial Board of Continuum: Lifelong Learning in Neurology and serves as chair of the Adult Neuroscience Specialty Steering Board for Epic. A. Wu is a member of the Epic Neuroscience Steering Board; has received speaker honoraria from the AAN; serves on the Editorial Advisory Board for Neurology Now; serves on a scientific advisory board and the speakers' bureau for Novartis and Lundbeck; and receives research support from Novartis, Department of Defense/Congressionally Directed Medical Research Program, NIH, Tuberous Sclerosis Alliance, and Today's and Tomorrow's Children Fund. D. Evans serves on the speakers' bureau for and has received funding for travel and speaker honoraria from the AAN; serves on the editorial review board for MGMA Connection; and serves as Chief Executive Officer of Texas Neurology.
References
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